WPR09FA062
WPR09FA062

HISTORY OF FLIGHT

On December 20, 2008, about 1521 mountain standard time, a Diamond DA 20-C1, N4196M, experienced an in-flight loss of control and descended into terrain about 1/2 mile northwest of the Alamo Lake State Park. The accident site is about 32 miles north of Wenden, Arizona. The airplane was substantially damaged, and the private pilot was killed during the solo instructional flight. The airplane was operated by Sabena Airline Training Center, Inc., Mesa, Arizona. Visual meteorological conditions prevailed. A Federal Aviation Administration (FAA) flight plan was filed, but was not opened. The flight was performed under the provisions of 14 Code of Federal Regulations Part 91, and it originated from Falcon Field, Mesa, about 1140.

Earlier during the morning of December 20, about 1028, the pilot telephoned the Prescott Automated Flight Service Station (AFSS) and filed a round robin flight plan from Falcon Field to Lake Havasu City Airport, Lake Havasu, Arizona, and return. The pilot informed the AFSS briefer that his cruise altitude would be 6,500 feet mean sea level (msl). He advised the briefer that he would acquire fuel at Lake Havasu before commencing the return portion of the flight.

The airplane's flight track and altitude were subsequently reconstructed by the National Transportation Safety Board investigator using data from the following sources: (1) nonvolatile memory contained in the airplane's Guardian Mobility SkyTrax global positioning system (GPS) data logger; and (2) FAA recorded radar supplemented by the airplane's Mode C altitude reporting transponder.

The data indicated that during the outbound portion of the flight between Falcon Field and Lake Havasu, between about 1208 and 1314, the airplane was flying above the flight planned altitude. For example, between 1224 and 1253, the airplane was flying above 12,000 feet, and it ultimately climbed to about 14,000 feet.

Approaching Lake Havasu the pilot descended, and he landed about 1340. The airplane's fuel tank was completely filled prior to the pilot initiating the return portion of his flight.

About 1447, the pilot departed Lake Havasu and headed toward Falcon Field. While en route, the pilot again climbed above the flight planned altitude. By 1506, when the airplane was about 20 miles west-northwest of the accident site, its altitude was about 9,400 feet.

By 1518:41, the east-southeast-bound airplane had over flown the Alamo Lake and was approaching its eastern shore. The airplane's altitude was about 7,400 feet. About 5 seconds later, the airplane reversed direction and headed back over the lake toward the western shore, arriving there by 1519:17, at 6,700 feet. During the next approximately 24 seconds, the airplane climbed in a northerly direction to 7,300 feet while remaining over land, several hundred yards west of the lake's western shoreline. (See the radar flight track for an image of this portion of the route.)

The airplane was last recorded on radar at 1519:41 and 1519:53. At these times its location (lateral distance) was about 300 feet from the 1,100-foot msl accident site. During this 12-second interval, the airplane's recorded altitude decreased from about 7,300 to 6,000 feet, as indicated by the airplane's Mode C altitude reporting transponder.

Alamo Lake is used for recreational purposes. Two fishermen reported to the Mohave County Sheriff and the Safety Board investigator that they were fishing together on the lake. They reported observing the accident airplane descending and never heard any engine noise. They stated that the airplane was spinning during the time they observed it, and they lost sight of the airplane upon its descent behind a hill, about 1/4-mile from their location.

The first witness stated that the airplane was spinning in a clockwise direction and completed a 360-degree turn every 1/2 second. The second witness stated the airplane was spinning in a counterclockwise direction and estimated that it completed a 360-degree turn every 2 seconds.

The first witness also reported that the airplane's nose was pointed between 20 and 30 degrees downward as it spun around. The airplane completed at least 8 turns as he watched it descend. The second witness reported that the descending airplane's nose was initially level with the horizon. Then, the nose lowered to at least a 60-degree downward angle seconds prior to his losing site of it.

PERSONNEL INFORMATION

The pilot, age 18, held a private pilot certificate with an airplane single engine land rating that he received on November 25, 2008, upon completion of Sabena's FAA approved 14 CFR Part 141 training curriculum. By the accident date, his total flight time and total time flying the accident model of airplane was about 94 and 69 hours, respectively. The pilot's total pilot-in-command time was about 52 hours, and his total pilot-in-command time flying the accident model of airplane was about 34 hours. All of the pilot's flight time was received during the 90-day period immediately preceding the accident.

The pilot held a first class aviation medical certificate. The certificate was issued without limitations in August 2008.

AIRPLANE INFORMATION

In 2007, the utility category airplane was manufactured in Canada by Diamond Aircraft Industries. A Teledyne Continental Motors engine (model IO-240-B(17), serial number 650258) and a Sensenich propeller (model W69EK7-63G, serial number A68265) were installed on the airplane.

Sabena operated and maintained the airplane on a program of annual and 100-hour inspections. On December 13, 2008, the airplane received its last 100-hour inspection at an indicated airframe and engine total time of 1,938 hours, as evidenced by the engine's recording tachometer. On this date, the airplane's maintenance records indicated a Hobbs meter time of 2,528 hours.

The airplane's dispatch log indicates that, at the start of the pilot's accident flight, the Hobbs meter registered 2,539.1 hours. At the crash site, the Hobbs meter registered 2,542.3 hours, and the engine's tachometer registered 1,949.3 hours. Accordingly, the accident flight's duration was 3.2 hours, and the airplane had been operated about 11 (engine) hours since its last 100-hour inspection.

A review of the airplane's maintenance records pertinent to the accident flight did not reveal any outstanding squawks or maintenance anomalies. The pilot who flew the airplane immediately prior to the accident flight reported that "there was nothing wrong with the engine instruments," and the "aircraft was functioning perfectly." The pilot did not make any squawks.

The airplane was equipped with a Guardian Mobility SkyTrax device, which is a combination GPS receiver, data logger, and satellite transmitter. This device transmitted the airplane's GPS location at predetermined intervals during the round robin flight. Via the Internet, Sabena's staff had the capability of monitoring the flight's progress upon receipt of the automated periodic transmissions from the airplane.

The airplane manufacturer provided the airplane with a flight manual that, according to the Chief, Flight Test, Aircraft Certification Transport Canada, must be carried in the airplane at all times. The pilot was required to operate the airplane in compliance with the flight manual's provisions.

A note in section 2.9 of the "Approved Maneuvers" section of the manual states the following: "Spinning NOT approved for aircraft equipped with altitude compensating fuel system." Sabena's director of maintenance reported that the optional altitude compensating fuel pump had been removed from the airplane in early 2008.

In pertinent part, in section 4.4.16 of the flight manual's "Normal Operating Procedure" section, information is provided that addresses entering and recovering from spins. The first listed recovery procedure is to place the airplane's throttle in the idle position. Section 4.4.17 provides a note regarding idle power operations. The note states "Turn fuel pump on for all low throttle operations, including...all flight operations when engine speed could fall below 1400 RPM (eg. stalls, descents, spins...)."

METEOROLOGICAL INFORMATION

During the pilot's telephonic receipt of a standard weather briefing, he was advised that high pressure prevailed in the area, the visibility was unrestricted, the sky was mostly clear, and no adverse weather conditions existed over the planned route of flight. The surface wind was from the east, between 5 and 10 knots. At 6,500 feet, the forecast wind was from 310 degrees at 10 knots.

The two witnesses who were located about 1/4 mile from the crash site reported that, when they made their observations, the surface wind was calm, the sky was clear, and the temperature was about 50 degrees Fahrenheit. There were no reports of blowing dust in the area.

COMMUNICATIONS

No FAA facility reported any communications with the accident airplane following departure from the Lake Havasu City Airport. The FAA did not receive a request to open the pilot's flight plan, which it had on file.

WRECKAGE AND IMPACT INFORMATION

The Safety Board investigator performed an examination of the 1,100-foot msl accident site and airplane wreckage. The examination revealed that a dry wash area, principally devoid of vegetation, was located south of the northward oriented airplane. The airplane came to rest against an outcrop of native vegetation near the side of the dry wash. Some of the vegetation in front and to the rear of the airplane's right wing was taller than the airplane. The vegetation did not appear impact damaged. No ground scar evidence consistent with the airplane's landing gear wheels was noted in the sandy area aft of the airplane.

The airplane was found in an upright, near wings level, nose low attitude. The engine compartment was resting in an estimated 6-inch-deep impact crater. The aft fuselage was cracked and broken in a downward direction. The tail was resting on the ground.

The spinner and engine compartment were crushed upward at an estimated 30-degree angle. No evidence of circumferential score marks or torsional deformation was noted on the propeller's metal spinner, the lower surface of which was flattened in an upward direction. The wood propeller was not broken from its attachment flange, the blade tips were present, and the leading edges were abraded.

All of the airplane's structural components and flight control surfaces were found attached to the airframe. A portion of the canopy was shattered.

An examination of the flight control surfaces and associated control mechanisms revealed continuity to the impact-damaged cockpit. The flaps were fully retracted, as evidenced by jack screw measurements. (The airplane's manufacturer refers to this retracted configuration as the "cruise" position.)

The throttle, mixture, and fuel controls also had continuity between the engine and the cockpit. The electric fuel pump switch was found in the "ON" position. The switch did not appear to have sustained any impact damage. (Note: By design, the two position toggle-type switch did not have a position/activation guard. The switch's preimpact position could not be confirmed.) The engine's ignition switch was found in the "OFF" position. A first responder reported having turned the switch off.

No fuel was observed in the fuselage's single fuel tank, which was observed ruptured in an impact-damaged area of the airplane. Fuel odor was noted in the sandy ground beneath the airplane. Fuel was found in the main fuel line to the engine and in the fuel bowl. The fuel filter was clean. There was no fire.

Following recovery of the airplane, its structure and engine were additionally examined. The airplane's digital radio transmitter was energized. It was found set to the 121.5 MHz emergency frequency.

The engine's crankshaft was manually rotated, and a corresponding rotation was noted in the accessory gears. Thumb compression was felt in all cylinders, and no evidence of preimpact damage was observed.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot's father reported to the Safety Board investigator that his son had been in excellent physical condition, and he did not use drugs. He had no history of becoming dizzy or disorientated when playing sports or performing other physical activities.

An autopsy was performed on the pilot by the Mohave County Medical Examiner, Lake Havasu City. The autopsy findings indicated the pilot died from "multiple blunt force injuries."

Forensic toxicology was performed on specimens from the pilot. The FAA's Civil Aerospace Medical Institute's (CAMI's) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, reported that no ethanol, carbon monoxide, cyanide, or any screened drugs were detected.

TESTS AND RESEARCH

SkyTrax Data Extraction

The SkyTrax data logger was recovered from its mounted location in the airplane. At the direction of the Safety Board investigator and under the supervision of the Transportation Safety Board of Canada (TSB), the data logger was examined by personnel from its manufacturer, Guardian Mobility Corporation, Ottawa, Canada.

The SkyTrax device was designed to periodically transmit flight path and associated data via the Internet. The data was viewable by Sabena personnel. In addition to the transmitted data, the device contained nonvolatile data that had not been transmitted by the time of the accident.

The device was found internally undamaged, and data from its nonvolatile memory was extracted and plotted. (See the TSB's "Engineering Report" for additional details.)

Engine Examination

The airplane's Teledyne Continental Motors (TCM) engine was further examined and test run under the Safety Board investigator's supervision at TCM's Mobile, Alabama, manufacturing facility. TCM's "Engine Operational Test Report" states that "[t]he operation of this engine was normal and did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower."

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Sabena Airlines Training Center, Inc., is located at Falcon Field, Mesa. The training facility is fully owned by Sabena Flight Academy N.V., which is located in Brussels, Belgium.

The FAA's Scottsdale, Arizona, Flight Standards District Office's principal operations inspector approved revision 2.2 of Sabena's training curriculum in August 2008, under Air Agency Certificate Number B4VS470K. Sabena provides FAA approved courses of instruction including private, commercial, instrument, and multiengine operations.

On a full-time basis, the company employs a chief instructor, an assistant chief instructor, check instructors, flight instructors, and ground instructors. In addition, the company employs a full-time quality and safety manager (Q & SM) who has responsibility over quality and safety issues. According to the Q & SM, the company employs about 100 persons. The company conducts FAR Part 141 and FAR Part 61 flight and ground training for foreign airline customers, and it operates a fleet of 15 Diamond DA20-C1 airplanes. Since Sabena began operating its fleet of DA20-C1s, the airplanes have accumulated a total of 37,177 flight hours, with 18,400 flight hours accumulated since January 1, 2008.

All students enrolled in the Sabena's FAA approved training course are provided with a booklet that encompasses topics including the school's operating rules, procedures, and curriculum. The accident pilot was provided with the booklet.

ADDITIONAL INFORMATION

Flight Training, Airwork, and Adherence to Curriculum

The following statement is written in the introduction section of Sabena's "Course Description" portion of the "Training Course Outline" booklet: "Students enrolled in this program will start with a student pilot license and obtain the FAA Commercial Pilot License with Instrument and Multi-engine ratings at the end of the course....The integration of different course phases (from Private Pilot to Commercial Pilot with Instrument and Multi-engine ratings) has been thoroughly laid out so as to enhance the student's learning process....It is of utmost importance that all stakeholders involved--be it students, schedulers, instructor, etc--understand the importance of strictly following the sequence in which the course has been designed."

Flight Training, Private Pilot

In the "Training Course Outline" booklet, under the "Safety Procedures and Practices" section, the following rule is published: "Spins will only be practiced when an instructor is on board."

The booklet indicates, by lesson number, the specific maneuvers the instructor is to teach. Students are to receive "spin awareness" training during several flight lessons, and on one lesson they are required to demonstrate proficiency. This training schedule is further incorporated into an "Exercise Card," onto which the instructor records a performance grade following each lesson.

A review of the "Exercise Card" for the accident student reveals that the student received spin awareness training on more than the minimum number of occasions. No record of this deviation from the school's curriculum was recorded in the training records. Nearing completion of the private pilot curriculum, the student exhibited a standard level of performance in spin awareness, as indicated by an entry in the "Exercise Card."

The accident student's certified flight instructor (CFI) subsequently reported to the Safety Board investigator that on October 7, 2008, he had provided the student with "spin awareness" flight training. During this training, the student entered and recovered from a spin. The CFI reported that when he teaches spins in the Diamond, the engine is not throttled to the idle setting when the spin is entered. (Note: according to Section 4.4.16 in the airplane's flight manual, the throttle should be set to the idle position.) The CFI stated that the student was able to perform a spin by himself at the conclusion of the lesson, and he "did not have to touch the controls at any time."

Sabena's chief instructor subsequently reviewed the student's training records in the area of spin awareness. The chief instructor acknowledged that the student had been provided with a greater number of spin awareness related training flights than the school's curriculum authorized. The chief instructor reported that "normally spin awareness training is accomplished by explaining the task elements required..." He stated that he was unable to ascertain how the task was actually accomplished because the CFI had not recorded that information in the training record.

Regarding follow-up action, the chief instructor made the following statements to the Safety Board investigator: "[Sabena] is emphasizing to flight instructor and students the importance of and the requirements to follow the training syllabus and note deviation from the syllabus in the training record. We are increasing surveillance of the training records and check instructors will identify deviations from the syllabus which are not explained." Also, the safety officer will brief all flight instructors in an upcoming meeting regarding spin awareness training.

Regarding the student's private pilot flight test, Sabena's Q & SM reviewed the accident pilot's flight training records. He reported that the student had received average or above average grades in simulated emergency approaches and landings, and systems and equipment malfunctions. The student’s records indicated that he failed the FAA private pilot practical test on the first attempt. The indicated reason for the failure was that the student “landed with a 30 knot tail wind during an emergency landing.” Thereafter, the student was given an additional 0.9 flight hours of dual instruction in ground reference maneuvers and simulated emergency approaches and landings. Following the additional dual flight instruction, the student satisfactorily completed the private pilot practical test on November 25, 2008.

Flight Training, Commercial Pilot

The pilot continued training at Sabena following acquisition of his private pilot certificate. The pilot was enrolled in the school's FAA approved integrated "Commercial, Instrument, Multi-Engine Course," and he was reportedly following the school's published "Training Course Outline."

The accident occurred during solo flight training in which the pilot was performing the second half of a practice cross-country navigation flight. The lesson was designated in Sabena's detailed training syllabus as Mission B7/B8. The training tasks to be accomplished were identified as encompassing preflight preparation and procedures, airport operations, takeoffs, landings, go-arounds, navigation, and post flight procedures.

The student's CFI reported to the Safety Board investigator that Mission B7/B8 was specifically intended to build cross-country flying experience. It was supposed to be a point-to-point mission, without performance of airwork flight maneuvers.

Sabena's Q & SM, along with a peer student of the accident pilot, reported that during the subject cross-country flight, climbing to 14,000 feet was not required by the curriculum. They opined that the accident student's climb to this altitude occurred for personal reasons.

Sabena's assistant chief instructor reported that performance of full rotation spins is not included in the school's approved training syllabus.

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